key: cord-0256810-6wa0tkiy authors: Freitas Coelho, J. M.; Ponte, G. A.; Gomes-Filho, I. S.; Passos, J. d. S.; Cruz, S. S.; Figueiredo, A. C. M. G.; Conceicao, S. d. S.; Silva, R. B.; das Merces, M. C. title: ASSOCIATION BETWEEN PERIODONTITIS AND METABOLIC SYNDROME IN A FAMILY HEALTH UNIT IN SALVADOR-BA date: 2021-06-04 journal: nan DOI: 10.1101/2021.06.03.21258301 sha: de23afb28b70e9433738b88c55a51347e4b6d35f doc_id: 256810 cord_uid: 6wa0tkiy Introduction: The metabolic syndrome is characterized by multiple disorders, and the in periodontitis, inflammation occurs in the tissues supporting the tooth, where in this process it is believed that the migration of oral bacteria and byproducts to the circulatory system occurs, with a systemic spread of inflammatory mediators. This study aims to verify the effect of periodontitis on the occurrence of the metabolic syndrome. Method: Cross-sectional study with 90 users of the Family Health Unit from Vale do Cambonas in Salvador-BA. Questionnaires were applied, physical / anthropometric and dental evaluation were performed, record of the results of laboratory tests was registered and evaluation of medical records. Data analysis: A bivariate and stratified analysis was performed, obtaining means and standard deviation for continuous variables, absolute and relative frequency for all variables, and multiple conditional logistic regression was performed to obtain the final model adjusted for potential confounders. Results: In the final sample 46,67% of participants had metabolic syndrome according NECP-ATP III criterion and 30, 00% had periodontitis. From those, 20.00% had severe periodontitis, 10% moderate periodontitis and none with mild periodontitis, according to the criterion proposed by Gomes-Filho et al. (2018). There was statistical significance in the association between periodontitis and MetS (ORcrude = 2.58, 95% CI [1.02 - 6.55]) / (ORadjusted = 2.63, 95% CI [1.01 - 6.80]) and severe periodontitis and MetS (ORcrude = 3.86, 95% CI [1.24 - 11.98]) / (ORadjusted = 4.14, 95% CI [1.29-13.29]). Conclusion: The main findings of this study indicate a positive association between periodontitis and metabolic syndrome, with a higher effect when the exposure was severe periodontitis. Metabolic syndrome (MetS) is defined as a complex disorder, represented by metabolic changes, such as dyslipidemia, arterial hypertension, glucose intolerance, central obesity and insulin resistance, which commonly occur together [1] [2] [3] . People diagnosed with MetS have an increased risk for cardiovascular adverse outcomes 4 , such as death caused by coronary disease [5] [6] [7] [8] , and higher risk for type 2 diabetes 9 . Thus, World Health Organization warns in regards to the increasing of noncommunicable diseases (NCD) that compose MetS and for the need of more studies in order to inform necessary control measures 10 . Recent studies showed the evolution of MetS, with a prevalence varying from 25% in Middle Eastern countries 11 to 50.2% in India 12 . In the United States of America (USA), the prevalence of MetS was estimated at 32.2% in the overall population, which increased for 34.6% in individuals older than 70 years old 13 . In Brazil, in spite of the lack of studies, a high prevalence of MetS has been reported 14 . Specifically, on a population based study by Oliveira et al. (2020) 15 , that estimated a mean prevalence of 38.4%; from these, 16.7% affects people at 18 to 39 years old, 45.7% happens with those aged 40 to 59 years old and 66.1% in those aged 60 years old or above. A higher prevalence was observed on the indigenous population, 63.4% 16 . Moreover, the prevalence of MetS in Brazil is higher in women, with a lower educational level and in the elderly 15 . Studies show that a chronic inflammatory process may predispose MetS due to the systemic dissemination of immunologic mediators and the increase in the production of inflammatory proteins, such as reactive C protein [17] [18] [19] [20] [21] . Besides, systemic inflammation can cause insulin resistance (IR) and/or hyperglycemia 19 . Therefore, periodontitis acts as a precursor of systemic inflammatory processes, since there is gingival inflammation associated with damage of periodontal ligament and alveolar bone, and also with the contamination of root cement, which is associated to the presence of specific gram-negative anaerobic bacteria [22] [23] [24] . It is believed that there is a migration of oral bacteria and byproducts directed to the blood flow, with a systemic dissemination of local inflammatory mediators. Therefore, periodontitis may be able to stimulate 17 having registry of laboratory results of triglycerides, HDL cholesterol and fasting glucose, dated 180 days before clinical and oral examination. Up to the reporting of the present study, we included 90 participants, and analyses were obtained with a study power of 51%, confidence level of 95% and exposure/non exposure ratio of 1:3, with a periodontits frequency of 40% for the non-exposed group and 20% for the exposed group 34 . Thus, the number of exposed participants was 27 (with periodontitis) and non-exposed was 63 (without periodontitis). We excluded from our sample participants who have had periodontal treatment in the last three months, with systemic infections, with HIV/AIDS, and pregnant women. Data collection was performed through a questionnaire, physical/anthropometric and dental assessment, and through the analysis of laboratorial examination results and patients registries. The questionnaire comprised personal and sociodemographic data, human biology, health care and dental assistance. Physical and anthropometric examination measured blood pressure in a calm environment, after at least 5 minutes of resting, and with a previous explanation of the procedure. The participant was guided to stay seated in a comfortable position, keeping legs uncrossed and feet on the ground, leaning the back on the chair (V-DBHA, 2007). We used a stethoscope from Premium® and sphygmomanometer from P.A.MED®, both properly calibrated. Weight and height were measured using a digital (Indi Peso Instrumentos®), with participants barefooted. Weight and height measures comprised Body Mass Index (BMI), according to Associação Brasileira para o Estudo da Obesidade 35 . We measured waist circumference based on the narrowest part of the waist (the space between the lower costal border and the iliac crest), and hip circumference based on the wider part of the hip and bigger lump of the gluteal region (150cmscale 0.5cm; and through the waist/hip ratio-WHRwaist circumference divided by hip circumference) 7, 35 . Clinical dental evaluation was performed by a dental surgeon, previously trained, in the dental Office of FHU Vale do Cambonas. Periodontal examination was performed using a Williams probe (from Hu-Friedy®), by the measurement of probe depth, given by the distance between gingival margin and the most apical portion of probe penetration, at six sites per tooth (mesial buccal, mid-buccal, distobuccal, mesio-lingual, mid-lingual, and disto-lingual) In these sites we also verified the presence of bleeding upon probing and measured gingival recession, which comprises the distance between gingival margin and cemento-enamel junction. Dental plaque index was also evaluated for the vestibular, lingual, mesial and distal faces from dental units, and we calculated clinical attachment loss (sum between probe depth and recession measure); these procedures were both performed on the same day Abdominal obesity by abdominal circumference Men > 102 cm * Women > 88 cm * Asian men > 90 cm ** (used as a parameter for south Americans) Women > 80 cm ** Triglycerides ≥ 150 mg/dL HDL Cholesterol Men < 40 mg/dL Women < 50 mg/dL Blood pressure ≥ 130mmHg or ≥ 85mmHg Fasting glucose ≥ 110 mg/dL* ≥ 100mg/dL** We performed a descriptive analysis for sociodemographic, lifestyle, human biology, health care and dental assistance information. Absolute and relative frequencies from relevant variables were obtained. Bivariate, stratified and multivariate analyses estimated the association between exposure and outcome variables. Pearson Chi-squared and T test estimated measures for independent variables. We adopted a 5% level of significance (p<0,05) and estimated Odds Ratios (OR) and its 95% Confidence Intervals (CI 95%). Regarding the association between periodontitis and MetS, we evaluated the change on the effect and confounding measures, and we assumed a predictive model using Mantel-Haenszel test, with a significance level of p≤ 0,20. Empirical and theoretical basis guided the selection of potential confounding variables, considering relative differences for each covariable's adjusted measures and crude association measure above 20%, Logistic regression was performed by a multivariate analysis, with effect modifying variables verified by maximum likelihood ratio (p<0,05) Since we did not identify any effect change, counfounding analysis was performed by the backward strategy. We considered potential confounding variables as those that promoted a change lower than 10% on the association measure, and we obtained a final model of association between periodontitis and MetS and a final model between severe periodontitis and MetS, both adjusted by age, alcoholic beverage drinking, family income and physical activity. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 4, 2021. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. When estimating ORs on models for the association between periodontitis 36 and MetS, and regarding criterion of IDF 40 (TABLE 5) , we only observed a significant statistical association between periodontitis and MetS. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 4, 2021. ; https://doi.org/10.1101/2021.06.03.21258301 doi: medRxiv preprint and periodontitis 20, 31, 32, 41 , other studies only observed it in women 42, 43 , while one study found this association only in men 44 . The bigger effect of this association regarding only severe periodontitis supports studies that only observed this association. Biological plausibility for the inter-relationship between periodontitis and MetS seems to be based by evidence showing the role of immunological markers in serum levels, such as IL-6 and TNF, that interconnect both diseases, in which combined effects have a synergic role on the coexistence of periodontitis and MetS 19, 20, 26, [44] [45] [46] [47] [48] . We did not observe an association between severe periodontitis, according to Gomes Regarding population assisted in health units in urban regions, the prevalence of MetS estimated in the present study is similar to the outcomes observed by Leitão and Martins (2012) 53 , for instance, a 56.7% MetS prevalence in Sao Paulo regions with low socioeconomic indexes, and 34.0% in those with higher socioeconomic indexes. The higher prevalence observed in lower socioeconomic status regions points to poverty as a risk factor for MetS 53 . All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 4, 2021. ; Metabolic Syndrome is associated with diabetes due to an increase in insulin resistance in individuals with MetS, 9 which results in a higher number of cardio metabolic factors 54 The prevalence of periodontitis observed in the present study was higher than the national average, which applyied the Community Periodontal Index (CPI) as a diagnosis criterion, where the prevalence of moderate to severe periodontitis was 15.8%, and severe periodontitis only 5.8% 59 . This difference is due to different criteria used for the diagnosis of periodontitis, where the use of CPI may underestimate the disease prevalence, due to the use of índex teeth and partial examination 60 . This outcome is confirmed by the elevated loss of LCA, which was significantly higher in those diagnosed with periodontitis. Similar findings were observed by Borges (2007) 18 that associated LCA loss to dental loss due to periodontal diseases. It is important to emphasize that Adachi and Kobayashi (2020) 61 observed an effect independent of dental loss on MetS. There was a positive association between periodontitis and serum triglyceride levels. Loscheet et al. (2000) 62 also observed a significant increase in these levels in individuals with periodontitis. 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(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity between periodontitis and MetS shown in literature, especially regarding periodontitis severity.The variety of findings and oppositions that are still present in the literature, however, show that this association is not yet well determined, showing a need for more studies that show this association. Finally, it is unquestionable the role of oral teams on individuals health, especially public, raising a professional profile more integrated with the promotion of periodontal health and overall wellbeing of health services users.